| As I discuss career options with a group of third | | | | succumb to modesty and self-effacement? Do |
| year medical students, I imagine a marketing | | | | psychiatrists have so great a level of job |
| brochure for psychiatry residencies in a world of | | | | satisfaction that they don't worry about money? I |
| mental health parity: | | | | wonder if the difference reflects a much larger |
| The brain is undeniably the most complex organ | | | | problem-- that psychiatrists have bought into a |
| of the human body. Treatments for diseases of | | | | societal impression that mental health is less |
| the mind and brain require the intricate | | | | valuable than physical health. |
| understanding of chemistry, physiology, and | | | | Support for this last concern can be found when |
| anatomy common to all branches of medicine, as | | | | one looks at the funding of mental health services |
| well as the ability to step outside of oneself to | | | | in general, and the tacit acceptance of the funding |
| objectively observe personality and emotion. The | | | | situation by psychiatrists and other mental health |
| psychiatrist must tolerate the unsettling | | | | caregivers. My insurer is required by statute to |
| awareness of the mysterious relationship | | | | provide coverage for mental health services up to |
| between mind and matter, and must help others | | | | about $2000 per year. On the other hand, there |
| find their own answers to the mysteries of the | | | | is no limit on payment for orthopedic injuries. The |
| human condition. No wonder that the masters of | | | | insured alcoholic is covered for the $1800 |
| medicine-those who work in the vast field of | | | | surgeon's fee for a fractured kneecap- and more |
| interventional psychiatry-are so valued by society. | | | | for the incidental hospital bill and the bills for |
| The time has come for my transition from | | | | physical therapy. If the alcoholic strikes his head, |
| psychiatric residency to psychiatric practice. The | | | | the radiologist receives $1200 to look at the MRI. |
| prospect of six-figure incomes suggests reward, | | | | And if he abruptly stops drinking for a week, the |
| at last, for years of work and debt. For the | | | | hospital is paid tens of thousands of dollars to help |
| employers, under the guarantee of income and | | | | him through withdrawal-- only to turn him out to |
| benefits lies the expectation of productivity. This | | | | drink again. Yet to treat the primary alcoholism, |
| productivity is not measured by patient | | | | the insurer will pay$2000. And if the patient has |
| satisfaction, symptom improvement, or reduced | | | | spent $2000 for treatment of depression earlier in |
| morbidity. Rather the name of the game is the | | | | the year, the insurer will continue to pay for |
| RVU, and the way to get more RVUs is to see | | | | kneecap fractures and MRIs, but not for |
| more patients in whatever time is available. I am | | | | treatment of the underlying cause of these |
| grateful for the opportunity to earn good money | | | | injuries-alcoholism. And other comparisons are |
| in the service of a challenging and rewarding | | | | equally dramatic. My insurer will pay $70,000 or |
| career. But I am also aware of the striking | | | | more for cardiac bypass to reduce a person's risk |
| difference between the salaries of psychiatrists | | | | of a heart attack, but only $2000 per year for |
| and the salaries of many other physicians. As a | | | | treatment of the same person's depression, to |
| former practitioner of one of medicine's more | | | | reduce risk of suicide. The narcotic addict is |
| lucrative specialties, I find myself comparing my | | | | allowed $2000 for treatment of heroin addiction, |
| apparent value now with my value then. Why is | | | | vs. hundreds of thousands of dollars for a |
| my work now worth less than half as much as | | | | secondary HIV infection. |
| my work as an anesthesiologist? | | | | The relatively low payments received by |
| At the end of a night in the crisis service last | | | | psychiatrists can be blamed to some extent on |
| week I walked past a group of patients huddled in | | | | psychiatrists themselves. They accept their own |
| the cold, waiting for the doors of the walk-in clinic | | | | devaluation when they sign for lower salaries or |
| to open. As I looked at their tired faces, I realized | | | | when they accept limitations on their ability to |
| the desperation they must feel to leave homes | | | | practice psychotherapy. They allow administrators |
| or homeless shelters at such a cold and early | | | | and others without medical training to dictate |
| hour, and make the trek to the clinic by foot or | | | | treatment plans. I am reminded of the late 1980's |
| by bus. Their pains were certainly as great as the | | | | when anesthesia was becoming perceived as a |
| pains of any of my patients presenting for | | | | technical trade, and was challenged by the |
| surgery. But for some reason there is less | | | | expanding statutory roles of nurse anesthetists. |
| outrage over their lack of care than would be the | | | | Rather than narrowing anesthesiology, the answer |
| case for a group of patients with untreated | | | | to devaluation was found by moving into critical |
| diabetes, appendicitis, or heart disease standing | | | | care and pain medicine and asserting the roles of |
| outside a hospital. I realized that like many in | | | | anesthesiologists as physicians. Similarly, |
| society, I had unwittingly accepted the scene | | | | cardiologists did themselves and their patients well |
| before me as adequate care for the mentally ill. | | | | when they laid claim to angioplasty, and called |
| The RBRVS, or resource-based relative value | | | | themselves interventional'. The new technology |
| scale, was instituted by Medicare in 1992 in an | | | | brought public respect and money, which then |
| attempt to standardize payments for physician | | | | yielded an explosion of new treatments. I don't |
| services. Relative value units, or RVU's, are | | | | know what the parallel path for psychiatrists will |
| assigned to physician services based on three | | | | be, but it is vital that as insights develop into brain |
| main factors: physician work, practice expenses, | | | | function, psychiatrists lay claim to them, grasp |
| and the cost of liability insurance. Physician work is | | | | them, and never let them go. There is nothing like |
| determined by several factors including time | | | | a brain procedure to grab society's interest and |
| required for the service, the technical skill and | | | | respect. In fact, I posit that the simple adoption |
| physical effort, the mental effort and judgment, | | | | of the term Interventional Psychiatry' would |
| and the amount of stress experienced by the | | | | increase the funding of psychiatrists and |
| physician due to the risk to the patient. To arrive | | | | psychiatric research by 20%. |
| at the fair value' of services, the number of | | | | The low priority of mental health services to |
| relative value units is multiplied by a universal dollar | | | | society is, of course, a complex issue. Stigma, |
| value, and adjusted slightly for practice location | | | | lack of lobbying resources, and denial of the |
| according to regional cost of living indices. | | | | impact of mental illness certainly play roles in the |
| In theory, this approach to payment provides a | | | | lack of public interest and investment in mental |
| level playing field for physicians. Payments for a | | | | health. Resources are thin for the unemployed and |
| cholecystectomy, for example, reflect the | | | | uninsured mentally ill, and the field of psychiatry |
| fortitude one must have to cut into someone's | | | | deserves kudos for attempting to meet the |
| body and the time required for surgery and | | | | needs of this population in return for little financial |
| postoperative care. Medicare strictly adheres to | | | | gain. But for patients with resources, we must |
| this formula, but in the world of private insurance | | | | recognize and advocate that mental health care is |
| some physicians' relative value units are more | | | | as important as treatment for a torn ACL, and |
| valuable than others. In my region, for example, | | | | deserves equitable reimbursement. The abilities to |
| Medicare has decided that the relative value of a | | | | laugh, to work, and to love are as vital as the |
| unit of physician work is about $38. The largest | | | | ability to return to beach volleyball. Psychiatrists |
| third-party payer in the area will pay psychiatrists, | | | | must realize that at some point, expectations of |
| pediatricians, or family physicians about $50 per | | | | relatively low reimbursements and medical |
| value unit. But orthopedists and radiologists, or | | | | standing become self-fulfilling prophecies, as our |
| podiatrists providing orthopedic services, are paid | | | | society tends to value those most who value |
| $100 per value unit. | | | | themselves. The correction of societal bias and |
| What accounts for the difference in payment? If | | | | the resultant devaluation of our services will |
| not due to stress, physical or mental effort, risk, | | | | require constant efforts to educate, negotiate, |
| technical proficiency, or practice cost, where does | | | | and assert the value of mental health care in a |
| the difference come from? Certainly not from | | | | healthy society. And psychiatrists, as the voices, |
| supply and demand, as in my area it is much | | | | faces, and business representatives of mental |
| easier to see an orthopedist this week than to | | | | health, will raise the status and treatment of their |
| see a psychiatrist within the next month. Does | | | | patients as they work to raise the scientific, and |
| the lower reimbursement reflect decades of poor | | | | yes, economic, status of themselves as |
| negotiating? Are psychiatrists more likely to | | | | physicians. |